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Fillable Employee Accident Report Template

The Employee Accident Report form is a crucial document that captures details of workplace incidents involving employees. This form helps ensure that all necessary information is recorded for safety evaluations and potential claims. If you've experienced an accident at work, it's important to fill out the form promptly by clicking the button below.

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Fillable Employee Accident Report Template

Content Overview

File Details

Fact Name	Description
Purpose	The Employee Accident Report form is used to document workplace accidents and injuries to ensure proper reporting and follow-up.
Mandatory Use	In many states, employers are required to use this form to comply with workers' compensation laws.
Information Collected	The form typically collects details such as the date, time, and location of the accident, as well as a description of the incident.
Employee Details	It includes sections for the injured employee's name, job title, and contact information to facilitate communication.
Witness Information	The form often allows for the inclusion of witness names and statements, which can be crucial for investigations.
State-Specific Forms	Some states have specific forms that must be used, governed by local workers' compensation laws.
Filing Deadline	Employers typically must submit the report within a certain timeframe after the accident occurs, often within 24 to 72 hours.
Confidentiality	The information provided on the form is generally kept confidential and is used solely for the purpose of managing the injury and ensuring compliance.
Follow-Up Actions	After submission, employers may be required to take specific actions, such as providing medical care or conducting safety reviews.

Sample - Employee Accident Report Form

Employee Incident Investigation Report

Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.

(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)

This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss

Date of incident:

This report is made by: Employee Supervisor Team Other_________

Step 1: Injured employee (complete this part for each injured employee)

Name:	Sex: Male Female		Age:

Department:	Job title at time of incident:

Part of body affected: (shade all that apply)	Nature of injury: (most	This employee works:
	serious one)	Regular full time
	Abrasion, scrapes	Regular part time
	Amputation	Seasonal
	Broken bone	Temporary
	Bruise	Months with
	Bruise
	Burn (heat)
	Burn (heat)	this employer
	Burn (chemical)	this employer
	Burn (chemical)
	Concussion (to the head)	Months doing
	Crushing Injury	this job:
	Cut, laceration, puncture
	Cut, laceration, puncture
	Hernia
	Illness
	Sprain, strain
	Damage to a body system:
	Other ___________

Step 2: Describe the incident

Exact location of the incident:

Exact time:


What part of employee’s workday? Entering or leaving work			Doing normal work activities
During meal period	During break	Working overtime Other___________________

Names of witnesses (if any):

Number of attachments:

Written witness statements:

Photographs:

Maps / drawings:

What personal protective equipment was being used (if any)?

Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details.

	Description continued on attached sheets:


Step 3: Why did the incident happen?
Unsafe workplace conditions: (Check all that apply)	Unsafe acts by people: (Check all that apply)
Inadequate guard	Operating without permission
Unguarded hazard	Operating at unsafe speed
Safety device is defective	Servicing equipment that has power to it
Tool or equipment defective	Making a safety device inoperative
Workstation layout is hazardous	Using defective equipment
Unsafe lighting	Using equipment in an unapproved way
Unsafe ventilation	Unsafe lifting
Lack of needed personal protective equipment	Taking an unsafe position or posture
Lack of appropriate equipment / tools	Distraction, teasing, horseplay
Unsafe clothing	Failure to wear personal protective equipment
No training or insufficient training	Failure to use the available equipment / tools
Other: _____________________________	Other: __________________________________

Why did the unsafe conditions exist?

Why did the unsafe acts occur?

Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may

have encouraged the unsafe conditions or acts? Yes No If yes, describe:

Were the unsafe acts or conditions reported prior to the incident?	Yes	No

Have there been similar incidents or near misses prior to this one?	Yes	No

Step 4: How can future incidents be prevented?

What changes do you suggest to prevent this incident/near miss from happening again?

	Stop this activity	Guard the hazard	Train the employee(s)	Train the supervisor(s)
	Redesign task steps	Redesign work station	Write a new policy/rule	Enforce existing policy

Routinely inspect for the hazard Personal Protective Equipment Other: ____________________

What should be (or has been) done to carry out the suggestion(s) checked above?

Description continued on attached sheets:

Step 5: Who completed and reviewed this form? (Please Print)

Written by:	Title:
Department:	Date:

Names of investigation team members:

Reviewed by:

Title:

Date:

Common mistakes

Filling out the Employee Accident Report form is crucial for documenting workplace incidents. However, several common mistakes can undermine the effectiveness of this important document. One frequent error is providing incomplete information. Employees may forget to include essential details such as the date, time, and location of the accident. This lack of specificity can lead to confusion and hinder the investigation process.

Another common mistake involves failing to describe the incident accurately. Some individuals may use vague language or omit critical facts about what happened. For example, stating that an employee "fell" without explaining how or why can leave significant gaps in the report. A clear and detailed account is necessary for understanding the circumstances surrounding the accident.

Additionally, many employees neglect to include witness statements. Witnesses can provide valuable insights into the incident, which can be crucial for determining liability and preventing future accidents. Omitting this information can weaken the report and limit the organization's ability to address safety concerns effectively.

Lastly, some individuals overlook the importance of signatures and dates. A report that lacks the necessary signatures may not be considered valid. It is essential for both the employee involved and any witnesses to sign the document to confirm its accuracy. Without proper signatures, the report may face challenges during any subsequent investigations or claims.

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